ACCOUNT SIGNING FORM

ACCOUNT SIGNING FORM
POLICE CO-OPERATIVE CREDIT UNION (ST. CHRISTOPHER & NEVIS) LTD.

T: 869-465-9554/0968/2241 F: 869-466-7946

First Floor. E. C. Daniel Building. Cayon Street. Basseterre, St. Kitts
INFORMATION REQUIRED FOR ALL BENEFICIAL OWNERS, DIRECTORS AND SIGNING OFFICERS
Beneficial OwnerSigning OfficerDirector
Mr.Mrs.Ms.Dr.
SingleMarriedDivorcedSeparatedWidowed
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Country of Birth
Nationality
YesNo
YesNo
If yes, please state:
Country of Residence:
Mailing Address:
Residential Address
City & State/Parish
Zip Code
Previous Address (if less than / year at present address):
TAXATION STATUS
YesNo
YesNo
PEP (POLITICALLY EXPOSED PERSONS) DECLARATION
A PEP is someone who is or was entrusted with a Prominent Public Function (e.g., head of state or government, politician, judicial or security force officials, senior civil servants, political party officials, ambassadors, senior executive of state-owned corporation or is an immediate family member (e.g., siblings, children. parents, in-laws) or close associate of such a person.
YesNo
If yes, please state your position
IDENTIFICATION DETAILS
Passport No.
Issuing Country
Issue Date

MonthDayYear
Date
Expiry Date

MonthDayYear
Date
Identification Type
Issuing Country
No.
Issue Date

MonthDayYear
Date
Expiry Date

MonthDayYear
Date
Identification Type
Issuing Country
No
Issue Date

MonthDayYear
Date
Expiry Date

MonthDayYear
Date
CONTACT DETAILS
Primary Contact No.
Secondary Contact No.
Fax
Email Address
example@example.com
EMPLOYMENT DETAILS
Self-EmployedFull-TimePart-TimeRetiredStudentUnemployed
Employer Name
Contact Number
Job Title
Occupation
Employer Address
REFERENCES
Name of Financial Institution
Address
Contact No.
Name & Designation
Company
Address
Contact No.
BENEFICIAL OWNERSHIP DETAILS (SELECT ONE)
A "Beneficial Owner* refers to the natural person who ultimately owns or controls a member and/or whose behalf transaction is conducted.
Name

First NameMiddle NameLast Name
Residential Address
City & State/Parish
Zip Code
Country
Date of Birth

MonthDayYear
Date
Nationality
I/We authorize the PCCU to release any information pertaining to the operation of my/our account(s) by mail, fax, or delivery either original or copies of documents any confidential information that you may have in your possession whenever it becomes necessary to do so for the following purposes: a) In order to verify the existence and condition of my account for credit bureaus and like agencies; b) In order to comply with directions of a regulatory body or agency. orders from a regulatory body or agency. court orders by any Court of competent jurisdiction within the Federation or under the provisions of any law of the Federation; is it c)In order to comply with reasonable and legitimate requests from other Financial Institutions in circumstances where necessary for completing business transactions on my behalf: d)In response to requests of persons providing services to the PCCU as long as those persons maintain confidentiality agreements with you; c) Where you have received written instruction(s)/permission from myself. my heirs or my legal representatives; and f) In accordance with the applicable laws and regulations of the Federation of Saint Christopher and Nevis. Thatall information provided (including any documents) regarding my/our application are true and correct to the best of my/our knowledge with the understanding that any misrepresentation could result in the denial of my/our application. I/We hereby acknowledge that whereas the above certification is binding on me/us and intended for the PCCU to rely on. I/we give the PCCU the authority, in addition to the certification, to use independent verification of the information given.
Print Name: Main Applicant
Signature
Authorized By (signature)
Officer Name
Date (DD/MM/YYY)

MonthDayYear
Date
Verified By (signature)
Officer Name
Date (DD/MM/YYY)

MonthDayYear
Date
Date (DD/MM/YYY)

MonthDayYear
Date
Should be Empty:

ACCOUNT SIGNING FORM

INFORMATION REQUIRED FOR ALL BENEFICIAL OWNERS, DIRECTORS AND SIGNING OFFICERS

TAXATION STATUS

PEP (POLITICALLY EXPOSED PERSONS) DECLARATION

IDENTIFICATION DETAILS

CONTACT DETAILS

EMPLOYMENT DETAILS

REFERENCES

BENEFICIAL OWNERSHIP DETAILS (SELECT ONE)